Stigma Struggles in the Rural Southern U.S.

By Marc Kolman, M.S.P.H.

February 16, 2010

This is my second blog for TheBody.com. I took on this project because I wanted to write about stigma and HIV in the Southern U.S. But it's proven harder to do than I thought and it's taking me far too long to write this second post.

The challenges of running a small non-profit in Durham, N.C., much less separating from my wife and thinking about my mom's cancer, have proved to be just about enough for me. But you don't need to hear about my personal life.

I've always wanted to write this story; and it is about HIV, stigma and the South. For two years in the '90s, I was health director for a small rural county in south central North Carolina. It was the most remote, isolated place I'd ever lived. I was already dealing with quite a bit of culture shock, having moved from progressive Santa Fe, N.M. The economics in this county were dismal. There were almost no jobs, no industry, and no entertainment or recreation.

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A large portion of the people who stayed in the county had little means to leave. For many, drugs and sex were the things to do. Not surprisingly, we had one of the highest rates of HIV infection in the state. And North Carolina, being in the Deep South, continues to have one of the higher HIV infection rates in the country.

With the support of a somewhat enlightened administrator of our local hospital, we were lucky enough to start a series of task forces to address broad-based community health issues -- HIV was one of them. We recruited just about everyone we could think of who was concerned about HIV, including our local newspaper editor. This editor was also one of the enlightened leaders in the community. She placed free fillers for us -- those spaces at the end of a newspaper article, where they have room at the end of a column -- which said things like "Teach your kids about HIV and AIDS." She soon moved on to someplace on the Outer Banks and I soon moved on to a different county.

I wanted to share this story because it has a lot to do with stigma and the rural South. First, the rural South is in the Bible Belt, which means that talking about drugs and sex is not easy. In the Bible Belt you don't schedule things on Wednesday evenings or Sundays, period, because of conflicts with church activities (did you know church meetings are on Wednesday evenings?). And, you don't talk much about things you're "not supposed" to be doing.

Stigma is the result of people's lack of comfort and ability to deal with real world issues, such as drugs and sex. Sexual identity falls under this category too. How many people have moved to more urban communities where tolerance is higher and their behaviors are more accepted? The lack of conversation and the inability to address issues in the community leads to stigma. Stigma leads to secrecy and shame, which tends to encourage higher-risk behaviors.

Second, I think it helps tremendously to get something in front of people and get them to keep thinking and talking about it. Eventually it becomes something that people are OK talking about. This is culture change -- helping people change what they think and what they do. After raising the issues and keeping them visibly in front of community leaders, maybe now it'll be a little easier for them to talk about drugs and sex.

Third, those people who try to make changes in a community that does not adapt well to change are often ostracized and not supported. It didn't take long for my ally from the local newspaper to leave town. And it didn't take long for me to leave town. The challenges of addressing changes significant enough, and that lie so deep within a community's cultural fabric, are difficult. The support is often not there to make it worthwhile for someone to stick with it long enough to make much of a difference. It is a challenge to do the real work that is needed in small rural communities, in the Southern U.S. and elsewhere, that have such a lack of resources -- financial, emotional, spiritual.

Now the HIV infection rate is 39th of 100 counties (13.2 cases per year per 100,000 over the past five years). Of course, the fact that the county is no longer near the top of the list isn't due to the support of this newspaper editor. We can't really tell, but it's probably due to years of continued work by the local public health authority and its many partners -- including the HIV task force. But I like to think that it will make a difference to engage the right people and support them; that it will make a difference to get people to face issues in their community, think about them, and talk openly about them. That persistence pays. Take the long view and continue to do the right thing.

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Marc Kolman is a long-term public health administrator and advocate. With a passion for social justice, Marc has worked in many settings, including state and local governments and non-profit agencies. Primary interests include HIV and issues affecting the deep south. Marc is currently the executive director of the Piedmont Health Care Consortium which envisions a society in which no one is limited by oppressions, health disparities, or social injustices. Marc lives in Carrboro N.C., is an avid cyclist and is the father of three daughters.

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